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Health Plan and Provider Collaboration…

Really?

Ken JandaPresident and CEO

Community Health Choice, Inc.

February 26, 2018

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About Community

• Community Health Choice, Inc. (Community) is a Texas non-

profit corporation (IRC 501(c)4), organized for the promotion

of social welfare and community benefit

• Licensed and regulated by the Texas Department of

Insurance as a Health Maintenance Organization (HMO) and

Third Party Administrator (TPA)

• A Safety Net Health Plan as defined by the Affordable Care

Act, focused on serving low-income populations

• Affiliate of the Harris County Hospital District (Harris Health

System); created by Harris Health in 1997

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Our Programs

Community serves over 425,000 Members in the following programs:

• Medicaid STAR Program for low-income children and pregnant

women (1997)

• Children’s Health Insurance Program (CHIP) for the children of low-

income parents, including CHIP Perinatal benefits for unborn children

(2006)

• Health Insurance Marketplace Plans offered to individuals under the

ACA, primarily with subsidized premiums for lower income families

(2014)

• Regional HMO coverage for State of Texas employees (ERS) (2015)

• Administrator for Marketplace plans offered by Sendero Health Plans

in Austin (2017)

• Administrator for collaborative safety net projects including TexHealth

3-Share insurance subsidies (2008), DSRIP (2013), and NAIP (2015)

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Service Area Map

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Health Care Triple Aim

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What Are Our Goals?

A Health Policy Home Run

First Base: Personal accountability for

health and financing

Second Base: Coverage for everyone

Third Base: Simplify funding and

administration of programs

Home Plate: Slow healthcare cost

increases through provider payment reform

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A Health Policy Home Run: Principles for Health Care Reform

1B: Personal accountability for health

Encourage healthy behaviors and consumerism

Everyone pays something: cost-sharing based on income

Choices of plans and benefits, with transparency of costs

2B: Coverage for everyone

A basic benefit plan for all based on age, disability, family need

Ability to “buy up” for additional services

Individual mandate or auto-enrollment, with subsidies based on age and income

3B: Simplify funding and administration of programs

Reduce administrative burden on providers and consumers through consistent program

administration across Medicare, Medicaid, and private plans

Eliminate complex supplemental provider funding in government programs

Require multi-year rate guarantees from insurers

HP: Slow healthcare cost increases through provider payment reform

Encourage coordinated, less fragmented care (medical homes, ACOs, etc.)

Restructure provider payments to reward efficiency and quality (value-based payments)

Assure fair payment rates across programs, including safety net providers

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Health Care System Still

in Need of Reform

In the past, we operated in a system that emphasized volume

where providers treated patients and payers reimbursed

providers for the cost of treatment - fee-for-service.

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Shift in our Health Care System

• Recognizing the need for payment reform that improves the performance and

sustainability of the U.S. health care system, a new strategy began developing

across the country - value-based care.

• ACOs in ACA, MACRA, DSRIP projects in Medicaid and other governmental

drivers, quickly followed by commercial carriers.

• Even with recent CMS backtracking, value-based contracting is the future

Quality of Care Cost Effectiveness Population Health Mgmt.

Value-Based Care

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Shift in our Health Care SystemLAN Alternative Payment Model Framework

Source: https://hcp-lan.org/groups/apm-framework-refresh-white-paper/?utm_source=LAN+Newsletter&utm_campaign=8b39f5033d-

DSRI_APM_Refresh_2017_05_23&utm_medium=email&utm_term=0_1b87e2051f-8b39f5033d-150318153

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Shift in our Health Care SystemPayment Reform Goals

Source: https://hcp-lan.org/groups/apm-framework-refresh-white-paper/?utm_source=LAN+Newsletter&utm_campaign=8b39f5033d-

DSRI_APM_Refresh_2017_05_23&utm_medium=email&utm_term=0_1b87e2051f-8b39f5033d-150318153

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Measuring Outcomes/Quality

• Healthcare Effectiveness Data and Information Set (HEDIS):o Standardized measures, some outcomes, but many process measures:

• Potentially Preventable Events (PPEs):o Admissions (PPAs)

o Readmissions (PPRs)

o Emergency room visits (PPVs)

• Cost effectiveness measured by Quality Adjusted Life Years (QALY):o Living longer is the best method to measure outcomes

o Being able to walk, talk, see, hear is better than not (quality of life)

o Being able to work and getting back to work faster is important to

employers/government entities that pay most of the cost

o Pain, suffering or financial burden of treatment should be worth the gain

o All things being equal, lower cost/less service with same outcome is a positive

outcome

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Healthcare Effectiveness Data

and Information Set (HEDIS)

• Sponsored by National Committee for Quality Assurance (NCQA)

• Tool used by more than 90 percent of America's health plans to

measure performance on important dimensions of care and service

• Consists of 81 measures across 5 domains of care

o Effectiveness of Care

o Access/Availability of Care

o Experience of Care (Patient Satisfaction)

o Utilization and Relative Resource Use

o Health Plan descriptive Information

• HEDIS makes it possible to compare the performance of health

plans on an "apples-to-apples" basis

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Texas Medicaid and the

Pay for Quality Program (P4Q)

• New program will kick-off CY 2018 putting 3% of MCO capitation at risk

• Designed to focus on prevention, chronic disease management and

maternal and infant health

• Goal – simple and easy to understand, reward high performance and

improvement and promote transformation and innovation

• Types of at-risk measures:

o HEDIS

o Potentially Preventable Events (PPEs)

• Performance on each measure is evaluated against:

o Performance against benchmarks (national HEDIS percentiles, actual to

expected ratio)

o Performance against self (previous year’s performance)

• New “Bonus Pool” measures; not at risk measures

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At-Risk Measures

Measure STAR CHIP STAR+PLUS

Adolescent Well Care X

Well Child Visits in the First 15 Months of Life X

Prenatal Care X

Postpartum Care X

Weight Assessment and Counseling for Nutrition X

Weight Assessment and Counseling for Physical Activity X

Upper Respiratory Infections X X

Potentially Preventable Emergency Visits X X X

Controlled Hemoglobin A1C X

Diabetes Screening Antipsychotics X

Cervical Cancer Screening X

Controlling High Blood Pressure X

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Bonus Measures

(Revenue Not at Risk)

Measure STAR CHIP STAR+PLUS

Potentially Preventable Admissions X

Potentially Preventable Readmissions X

Potentially Preventable Complications X

Childhood Immunization Status (Combo 10) X

Low Birth Weight X

Prevention Quality Indicator – (PQI) Composite X

CAHPS Children/Adults – Good access to urgent care X (C) X (C) X (A)

CAHPS Adults – Rating their health plan a 9 or 10 X X

CAHPS Caregivers – Rating their child’s health plan a 9 or 10 X

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HEDIS – How are we Doing?

Measure (CY 2015)Community’s

Results

NCQA

90th Percentile

Adolescent well-care 85.38% 83.75%

Prenatal care (STAR) 89.66% 91.73%

Postpartum care (STAR) 63.22% 72.43%

Childhood immunizations 70.85% 78.06%

Well child check-up in the first 15 months of life 59.62% 73.88%

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Consumer Assessment of Healthcare

Providers and Systems (CAHPS)

• CAHPS Surveys are a set of tools that assess patient satisfaction with the

experience of care and service. Developed and maintained by the National

Committee for Quality Assurance (NCQA) and the Agency for Health Research

and Quality (AHRQ).

• Increasingly important for providers and health plans

• Community Rating above the 2015 NCQA 95th percentile.

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Why Focus on Cost Control?

Chandra, Amitabh, Anupam B. Jena, and Jonathan S. Skinner. 2011. "The Pragmatist's Guide to Comparative Effectiveness Research."

Journal of Economic Perspectives, 25(2): 27–46.

• More services do not necessarily improve outcomes

• More costly technologies do not necessarily produce better outcomes

• Patients have limited ability to compare outcomes to cost (i.e., value).

Lack of transparency of provider pricing is a big problem.

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Payer/Provider Relationship Moving Forward: Paradigm Shift

• Integrated delivery systems o Improved ability to coordinate care

o New payment mechanisms (bundled payments, gain sharing, and capitation)

o Understanding insurance risk (prevalence) vs. management risk (resource utilization)

• Impact of data o Sharing of EHR data

o Thinking populations, not just patients

o Building trust between providers and insurers

o Consumerism requires more cost transparency

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Community is Helping

Providers Transition

Category 2: • Provider Incentive Program (PIP) for primary care and Ob-Gyns

(Fee-for-Service with incentives)o Foundational incentives including electronic medical records

o Incentives for PPVs

o HEDIS incentives

Category 3:• Bundled payment pilot for maternity

o Mom and baby

o Includes prenatal and post-partum care plus nursery/NICU

Category 4:• Full-risk capitation with experienced integrated systems like Kelsey

Seybold

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Health Care Moving Forward

No matter what happens in DC, it’s time for payers AND

providers to learn to trust each other and work collaboratively to

navigate the transformation of our health care delivery system.

Health Plan and Provider Collaboration….Really!

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Questions & Discussion

Contact Information:

Ken Janda

(713) 295-2410

Ken.Janda@communityhealthchoice.org